A disruption or break in the continuity of the structure of bone
Fractures
Description
A disruption or break in the continuity of the structure of bone
Traumatic injuries account for the majority of fractures
Description
Described and classified according to:
Type
Communication or noncommunication with external environment
Anatomic location
Types of Fractures
Fig. 61-4
Classification by Communication with
External Environment
Fig. 61-5
Classification by Fracture Location
Fig. 61-6
Description
Described and classified according to:
Appearance, position, and alignment of the fragments
Classic names
Stable or unstable
Description
Closed (also called simple) skin remain intact
Open (also called compound) skin is breeched.
Description
Stable fractures
Occur when a piece of the periosteum is intact across the fracture
External or internal fixation has rendered the fragments stationary
Description
Unstable fractures
Grossly displaced
Poor fixation
Clinical Manifestations
Immediate localized pain
Function
Inability to bear weight or use affected part
Guarding
May or may not see obvious bone deformity
Fracture Healing
Reparative process of self-healing (union) occurs in the following stages:
Fracture hematoma (d/t bleeding, edema)
Granulation tissue → osteoid (3 – 14 days post injury)
Callus formation (minerals deposited in osteoid)
Fracture Healing
Reparative process of self-healing (union) occurs in the following stages:
Ossification (3 wks – 6 mos)
Consolidation (distance between fragments decreases → closes).
Remodeling (union completed; remodels to original shape, strength)
Bone Healing
Fig. 61-7
Collaborative Care
Overall goals of treatment:
Anatomic realignment of bone fragments (reduction)
Immobilization to maintain alignment (fixation)
Restoration of normal function
Collaborative Care
Fracture Reduction
Closed reduction
Nonsurgical, manual realignment
Open reduction
Correction of bone alignment through a surgical incision
Collaborative Care
Fracture Reduction
Traction (with simultaneous counter-traction)
Application of pulling force to attain realignment
Skin traction (short-term: 48-72 hrs)
Skeletal traction (longer periods)
See Table 61-7
Collaborative Care
Fracture Immobilization
Casts
Temporary circumferential immobilization device
Common following closed reduction
Casts
Fig. 61-9
Collaborative Care
Fracture Immobilization
External fixation
Metallic device composed of pins that are inserted into the bone and attached to external rods
Collaborative Care
Fracture Immobilization
Internal fixation
Pins, plates, intramedullary rods, and screws
Surgically inserted at the time of realignment
Collaborative Care
Fracture Immobilization
Traction
Application of a pulling force to an injured part of the body while countertraction pulls in the opposite direction
Collaborative Care
Fracture Immobilization
Purpose of traction:
Prevent or reduce muscle spasm
Immobilization
Reduction
Treat a pathologic condition
Nursing Management
Nursing Assessment for Fractures
Brief history of the accident
Mechanism of injury
Special emphasis focused on the region distal to the site of injury
Nursing Management
Nursing Assessment
Neurovascular assessment
Color and temperature
cyanotic and cool/cold: arterial insufficiency
Blue and warm: venous insufficiency
Capillary refill (want < 3 sec)
Peripheral pulses (↓ indicates vascular insufficiency)
Nursing Management
Nursing Assessment
Neurovascular assessment
Edema
Sensation
Motor function
Pain
Nursing Management
Nursing Diagnoses
Risk for peripheral neurovascular dysfunction
Acute pain
Risk for infection
Nursing Management
Nursing Diagnoses
Risk for impaired skin integrity
Impaired physical mobility
Ineffective therapeutic regimen management
Nursing Management
Nursing Implementation
General post-op care
Assess dressings/casts for bleeding/drainage
Prevent complications of immobility
Measures to prevent constipation
Frequent position changes/ ambulate as permitted
ROM exercised of unaffected joints
Deep breathing
Isometric exercises
Trapeze bar if permitted
Nursing Management
Nursing Implementation
Traction
Ensure:
No frayed ropes, loose knots
Ropes in pulley grooves
Pulley clamps fastened securely
Weights must hang freely
Appropriate body alignment
Inspect skin
Around slings
Around pins
Nursing Management
Nursing Implementation: Cast care
Casts can cause neurovascular complications if
Too tight
Edematous
Frequent neurovascular checks
Ice and elevation during early phase
See Table 61-10
Complications of Fractures
Infection
Open fractures and soft tissue injuries have incidence
Osteomyelitis can become chronic
Complications of Fractures
Infection
Collaborative Care
Open fractures require aggressive surgical debridement
Post-op IV antibiotics for 3 to 7 days (prophylactic)
Complications of Fractures
Compartment Syndrome
Condition in which elevated intracompartmental pressure within a confined myofascial compartment compromises the neurovascular function of tissues within that space
Causes capillary perfusion to be reduced below a level necessary for tissue viability
Complications of Fractures
Compartment Syndrome
Two basic etiologies create compartment syndrome:
Decreased compartment size (dressings, splints, casts)
Increased compartment content (bleeding, edema)
Complications of Fractures
Compartment Syndrome
Clinical Manifestations
Six Ps
Paresthesia (unrelieved by narcotics)
Pain (unrelieved by narcotics)
Pressure
Complications of Fractures
Compartment Syndrome
Clinical Manifestations
Six Ps:
Pallor (loss of normal color, coolness)
Paralysis
Pulselessness (decreased/absent pulses)
Complications of Fractures
Compartment Syndrome
Clinical Manifestations
Six Ps:
Patient may present with one or all of the six Ps
Compare extemities
Complications of Fractures
Compartment Syndrome
Clinical Manifestations
Absence of peripheral pulse = ominous late sign
Myoglobinuria
Dark reddish-brown urine
Complications of Fractures
Compartment Syndrome
Collaborative Care
Prompt, accurate diagnosis is critical
Early recognition is the key
Do not apply ice or elevate above heart level
Complications of Fractures
Compartment Syndrome
Collaborative Care
Remove/loosen the bandage and bivalve the cast
Reduce traction weight
Surgical decompression (fasciotomy)
Complications of Fractures
Venous Thrombosis
Veins of the lower extremities and pelvis are highly susceptible to thrombus formation after fracture, especially hip fracture
Complications of Fractures
Venous Thrombosis
Precipitating factors:
Venous stasis caused by incorrectly applied casts or traction
Local pressure on a vein
